Anda di halaman 1dari 1

FORMULIR PENDAFTARAN

UPACARA PENYERAHAN IJAZAH (UPI)


{khusus bagi alumni FE, FHISIP, FMIPA, FKIP(non PGSD/PGPAUD)
yang tidak berbasis pokjar/mandiri}

1. NIM :

2. N a m a : ...............................................................................................

3. Program Studi : ...............................................................................................

4. UPBJJ-UT : SURABAYA

5. A l a m a t : ...............................................................................................

...............................................................................................

6. Telepon / HP : ...............................................................................................

7. Ukuran Toga : XL / L / M / S (pilih salah satu)

8. Keluarga : Ikut / Tidak (pilih salah satu)

................................., .................................

( ……………………………………....................……. )